Temporal trends in the epidemiology, management, and outcome of sepsis-A nationwide observational study

Albumin use in patients with septic shock-Post-hoc analyses of an international randomised fluid trial

BACKGROUND

Albumin administration is suggested in patients with sepsis and septic shock who have received large volumes of crystalloids. Given lack of firm evidence, clinical practice variation may exist. To address this, we investigated if patient characteristics or trial site were associated with albumin use in septic shock.

METHODS

We conducted a post-hoc study of the CLASSIC international, randomised clinical trial of fluid volumes in septic shock. Associations between selected baseline variables and trial site with albumin use during ICU stay were assessed in Cox models considering death, ICU discharge, and loss-to-follow-up as competing events. Baseline variables were first assessed individually, adjusted for treatment allocation (restrictive vs. standard IV fluid), and then adjusted for allocation and the other baseline variables. Site was assessed in a model adjusted for allocation and baseline variables.

RESULTS

We analysed 1541 of 1554 patients randomised in CLASSIC (99.2%). During ICU stay, 36.3% of patients in the restrictive-fluid group and 52.6% in the standard-fluid group received albumin. Gastrointestinal focus of infection and higher doses of norepinephrine were most strongly associated with albumin use (subgroup with highest quartile of norepinephrine doses, hazard ratio (HR) 2.58, 95% CI 1.89 to 3.53). HRs for associations between site and albumin use ranged from 0.11 (95% CI 0.05 to 0.26) to 1.70 (95% CI 1.06 to 2.74); test for overall effect of site: p < .001.

CONCLUSIONS

In adults with septic shock, gastrointestinal focus of infection and higher doses of norepinephrine at baseline were associated with albumin use, which also varied substantially between sites.

C-reactive protein and procalcitonin during course of sepsis and septic shock

OBJECTIVE

The study investigates the diagnostic and prognostic value of C-reactive protein (CRP) and procalcitonin (PCT) in patients with sepsis and septic shock.

BACKGROUND

Limited data regarding the prognostic value of CRP and PCT during the course of sepsis or septic shock is available.

METHODS

Consecutive patients with sepsis and septic shock from 2019 to 2021 were included monocentrically. Blood samples were retrieved from the day of disease onset (day 1), day 2, 3, 5, 7, and 10. Firstly, the diagnostic value of CRP and PCT for the diagnosis of a septic shock, as well as for the discrimination of positive blood cultures, was tested. Secondly, the prognostic value of the CRP and PCT was tested for 30-day all-cause mortality. Statistical analyses included univariable t-tests, Spearman's correlations, C-statistics, and Kaplan-Meier analyses.

RESULTS

A total of 349 patients were included, of which 56% had a sepsis and 44% a septic shock on day 1. The overall rate of all-cause mortality at 30 days was 52%. With an area under the curve (AUC) of 0.861 on day 7 and 0.833 on day 10, the PCT revealed a superior AUC than the CRP (AUC 0.440-0.652) with regard to the discrimination between patients with sepsis and septic shock. In contrast, the prognostic AUCs for 30-day all-cause mortality were poor. Both higher CRP (HR = 0.999; 95% CI 0.998-1.001; p = 0.203) and PCT levels (HR = 0.998; 95% CI 0.993-1.003; p = 0.500) were not associated with the risk of 30-day all-cause mortality. During the first 10 days of ICU treatment, both CRP and PCT declined irrespective of clinical improvement or impairment.

CONCLUSION

PCT was a reliable diagnostic tool for the diagnosis of septic shock compared to CRP. Both CRP and PCT were shown to have poor predictive value with regard to 30-day all-cause mortality and were not associated with the risk of all-cause mortality in patients admitted with sepsis or septic shock.

Trends in mortality after a sepsis hospitalization: a nationwide prospective registry study from 2008 to 2021

BACKGROUND

Few studies have reported on mortality beyond one year after sepsis. We aim to describe trends in short- and long-term mortality among patients admitted with sepsis, and to describe the association between clinical characteristics and mortality for improved monitoring, treatment and prognosis.

METHODS

Patients ≥ 18 years admitted to all Norwegian hospitals (2008-2021) with a first sepsis episode were identified using Norwegian Patient Registry and International Classification of Diseases 10th Revision codes. Sepsis was classified as implicit (known infection site plus organ dysfunction), explicit (unknown infection site), or COVID-19-related sepsis. The outcome was all-cause mortality. We describe age-standardized 30-day, 90-day, 1-, 5- and 10-year mortality for each admission year and estimated the annual percentage change with 95% confidence interval (CI). The association between clinical characteristics and all-cause mortality is reported as hazard ratios (HRs) adjusted for age, sex and calendar year in Cox regression.

RESULTS

The study included 222,832 patients, of whom 127,059 (57.1%) had implicit, 92,928 (41.7%) had explicit, and 2,845 (1.3%) had COVID-19-related sepsis (data from 2020 and 2021). Trends in overall age-standardized 30-day, 90-day, 1- and 5-year mortality decreased by 0.29 (95% CI - 0.39 to - 0.19), 0.43 (95% CI - 0.56 to - 0.29), 0.61 (95% CI - 0.73 to - 0.49) and 0.66 (95% CI - 0.84 to - 0.48) percent per year, respectively. The decrease was observed for all infections sites but was largest among patients with respiratory tract infections. Implicit, explicit and COVID-19-related sepsis had largely similar overall mortality, with explicit sepsis having an adjusted HR of 0.980 (95% CI 0.969 to 0.991) and COVID-19-related sepsis an adjusted HR of 0.916 (95% CI 0.836 to 1.003) compared to implicit sepsis. Patients with respiratory tract infections have somewhat higher mortality than those with other infection sites. Number of comorbidities was positively associated with mortality, but mortality varied considerably between different comorbidities. Similarly, number of acute organ dysfunctions was strongly associated with mortality, whereas the risk varied for each type of organ dysfunction.

CONCLUSION

Overall mortality has declined over the past 14 years among patients with a first sepsis admission. Comorbidity, site of infection, and acute organ dysfunction are patient characteristics that are associated with mortality. This could inform health care workers and raise the awareness toward subgroups of patients that needs particular attention to improve long-term mortality.

A nationwide study on characteristics and outcome of cancer patients with sepsis requiring intensive care

BACKGROUND

Sepsis is the leading cause of admission to the intensive care unit (ICU) for cancer patients and survival rates have historically been low. The aims of this nationwide cohort study were to describe the characteristics and outcomes of cancer patients admitted to the ICU with sepsis compared with other sepsis patients requiring ICU admission.

MATERIAL AND METHODS

This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014 and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria. Clinical characteristics and outcomes of sepsis patients with cancer were compared to those without cancer.

RESULTS

In the study period, 235 of 971 (24%) patients admitted to Icelandic ICUs because of sepsis had cancer, most often a solid tumour (100), followed by metastatic tumours (69) and haematological malignancies (66). Infections were more often hospital-acquired in cancer patients (52%) than other sepsis patients (18%, p < 0.001) and sites of infections differed, with abdominal infections being most common in patients with solid and metastatic tumours but lungs and bloodstream infections in haematological malignancies. The length of stay in the ICU was shorter for sepsis patients with metastatic disease than other sepsis patients (2 vs. 4 days, p < 0.001) and they were more likely to have treatment limitations (52 vs. 19%, p < 0.05). Median survival of patients with metastatic disease was 19 days from ICU admission. The 28-day mortality (25%) of solid tumour patients was comparable to that of sepsis patients without cancer (20%, p < 0.001).

CONCLUSIONS

Cancer is a common comorbidity in patients admitted to the ICU with sepsis. The clinical presentation and outcome differs between cancer types. Individuals with metastatic cancer were unlikely to receive prolonged invasive ICU care treatment. Comparable short-term outcome was found for patients with solid tumours and no cancer.